Provider Demographics
NPI:1053600809
Name:BAE, GICHUL
Entity type:Individual
Prefix:
First Name:GICHUL
Middle Name:
Last Name:BAE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 SHATTO PL
Mailing Address - Street 2:STE 208
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1836
Mailing Address - Country:US
Mailing Address - Phone:213-382-2030
Mailing Address - Fax:866-438-5974
Practice Address - Street 1:440 SHATTO PL
Practice Address - Street 2:STE 208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1836
Practice Address - Country:US
Practice Address - Phone:213-382-2030
Practice Address - Fax:866-438-5974
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13472171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC13472OtherACUPUNCTURE